Vaginal examination in labour - what do women say?

The subject of vaginal examination is contentious, as Debbie Chippington Derrick has rightly pointed out in her article on page 8 and, despite the NICE guidelines, there is scant evidence as to how, when or why they should be performed.

My aim in this short article is to explore what some women say about vaginal examination and to consider what this means for health professionals and for women as users of the maternity services. The quotes I use in the article are all taken from research that I undertook for a PhD.1 In my research, I interviewed ten women, six who were pregnant for the first time and four who were pregnant with their second child. All women were interviewed twice: once towards the end of their pregnancy, and a second time approximately two weeks after the birth of their baby. Interviews took place in the woman's home and were tape-recorded with her written consent. All names have been changed to protect participants' confidentiality.

Pregnancy - an absence of information

The most striking feature of the interviews with women in pregnancy is the absence of information that they had been given. All the participants in my research had attended some kind of antenatal preparation: some had been to sessions run by the NHS, some to NCT classes and some to both. I asked women who were pregnant for the first time if they could remember vaginal examination being discussed during these classes, but none of them could recall this. As one woman remarked:

'It's funny, because I've been to all the classes and no-one's mentioned anything about internals at all ... there's been nothing said about them at all. So how often do you think I'll have them done?' Anna, 37 weeks pregnant, first baby

Another participant also worked as a midwife. She recalled:

'I don't remember it being in the antenatal classes really, not ... not specifically. In saying that, I think they said that ... when they're talking about progress in labour they said, "Oh, you'll be examined and it'll be like 4cms or whatever and you've got to get to 10cms," but they didn't say what happens throughout a VE, d'you know what I mean? Does that make sense?' Geraldine, 36 weeks pregnant, first baby/also a midwife

It seems that, despite the fact that they tried to prepare for labour and birth, it was hard for women to get clear information about this common procedure and what it actually entails. In fact, all the women in my study did know something about vaginal examination, but they indicated that they had got this information from friends and/or books they had read, rather than from midwives or NCT teachers. Not surprisingly, the information that women had was therefore somewhat limited. One woman was under the impression that the examination was only done as a 'one off ' to confirm that labour had started but, during the interview, she picked up on the fact that I referred to vaginal examinations in the plural. Our conversation went as follows:

Hope: 'D'you mean I'll have more than one?'
Mary: 'Well, yes, they're usually done four hourly, though it often varies so, yeah, you might have several ... but you don't have to have them done at all, they can't do them without your consent and you can say "No."'
Hope (in tones of amazement): 'You mean I have a choice?'

It is deeply worrying that a woman can reach the late stages of pregnancy without realising that she can choose to decline any or all medical interventions, from something quite benign, such as measuring blood pressure, to something as intimate as vaginal examination. After the birth - mixed feelings In the interviews after the birth of their baby, many participants commented that vaginal examination was painful or uncomfortable. One woman recalled the experience with great clarity:

'The second one I had, yeah, actually, I found that quite horrific ... I decided, it was me that said "I would like to have my waters broken for me" thinking it was going to make things quicker, so it was my decision to have it done but I'd read about having it done and that it was painless and that it was fine and that it was just like a crochet hook, so I'm thinking "Oh, this is going to be fine" but I found it really horrible ... I knew it was going to involve having a thing stuck up inside me but it seemed to take ages and it felt just awful, I felt horrible, I hated the feeling, it was a physical thing "eugh, this is really horrible" but, you know, it was my decision to have it done and at the end of the day I'm sure it was the right thing to do.' Barbara, 2nd baby, 12 days postnatal

It is interesting to note the responsibility that Barbara takes for this experience and the way that she tries to justify it to herself as 'the right thing to do'. However, for some women the discomfort was mitigated by what they perceived as practical necessity. For example, one woman who also had a 2-year old daughter said:

'She [the midwife] just examined me on the floor but it was really, really painful, it just hurt and I was going "Ow, ow, stop" ... She tried her best and I know it was necessary to do it, because I did want to know about sorting Susy [her older child] out and going in to hospital but it did really hurt, but then it was fine once she'd done it and I was glad I knew what was happening.' Kate, 2nd baby, 2 weeks postnatal

'[The midwife] told me I was 7cms [dilated] and that was great, that came at just the right time, because I was beginning to wobble and think I needed more painkillers, but then I thought "no, I can do this"' Jill, first baby, 15 days post-birth

However, another struck a more wistful note: 'It would be nice if they could tell without having to do an internal, wouldn't it? You know, if they could say "oh, you're this far, or this far, or this far" ... some sort of update along the way so that, you know, you don't have to have VEs at all ... [voice trails off] Kate, second baby, 11 days post-birth

What can we learn?

The evidence from women in this study indicates that health professionals have a lot to learn. Most importantly, the subject of vaginal examination needs to be discussed in pregnancy, so that women know what it entails, why it might be offered, what information it can provide (and just as importantly, its limitations), and their absolute right to decline the procedure. We know that most women do not attend pregnancy preparation classes so, although vaginal examination can and should be discussed in these group situations, it should also be raised with all women on a one-to-one basis during pregnancy. Alongside those discussions, there needs to be an acknowledgement that vaginal examination may be uncomfortable or painful. Several women in this study said that midwives prepared them for the procedure saying it was similar to a cervical smear, but women felt this was very misleading and unhelpful.

It has been suggested that some women find vaginal examination traumatic because they have previously experienced sexual abuse. However, I think we should also recognise that the procedure may be traumatic for all women, whatever their history. Vaginal examination can be an enormously useful and important examination. It can provide information about cervical dilation and, just as importantly, the position of the baby, that may have a direct impact on progress in labour and that is difficult to access in any other way. However, just as with any other procedure, it has its limitations. It is one of a range of tools that midwives and doctors can use to assess labour and, on its own, it is severely limited. It should be used in conjunction with a whole range of tools that can also be used to assess labour, such as observing a woman's behaviour and the noises she makes. Most of all, it must only ever be done once the woman has given her clear consent and, just as importantly, the midwife or doctor doing the procedure must stop immediately if the woman asks or if she becomes distressed. Anything less can surely be regarded as assault.

References

Stewart, M. (2008) Midwives' discourses on vaginal examination in labour, University of the West of England: unpublished PhD dissertation